root resorption Flashcards
influences on dentinoclast activity
upregulates by RANKL, OPG downregulates (signalling molecules)
RANKL stimulation
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- Parathyroid hormone B3, and interleukin 1B
- Bacterial lipopolysaccharides
- Trauma (physical, chemical)
- Chronic inflammation
surfaces that are involved
- Periodontal ligament
- Cementum – particularly the non mineralised layer
- Predentine - non collagenous components
All act to prevent resorption – but when damaged the resorption process can begin
* Multinucleate giant cells in bone – trauma means that cementum lost so bone in contact with dentine = resorption
Predentine prevents internal dentine from resoprting
enamel to PDL 20% people have resorption due to change in anatomy
types of root resorption
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internal
* inflammatory
* replacement
external
* inflammatory
* repalcement
* cervical
* surface
extraoral clinical findings and tests to assess for all restorative work
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Smile line -* if there is a consideration for Endodontic Microsurgery *
* post surgical recession or scaring is an aesthetic risk Tooth in question
* external cervical resorption in Upper incisors – know as possible issue
Coronal integrity of remaining tooth and restoration quality
* can the tooth be predictably restored after treatment
Colour
* e.g. presence pink spot
Periodontal pocketing with a PCP12 probe both vertically and horizontal
* is there a periodontal communication with the resorption
* isolate 6PPC around tooth to assess root and amount resorption – KEY for endo dx
Sinus *including location in relation to mucogingival junction *
* has the internal resorption perforated the root canal
Swelling
* associated with periradicular disease
Apical tenderness
* associated with periradicular disease
Tenderness to percussion
* a test of the PDL not necessarily periradicular disease
* careful
* high pitched tinny notes
Mobility
* no physiological mobility and high pitched percussion
Occlusal contact in ICP and guidance
* is the tooth in function and prudent to retain
Integrity of adjacent teeth
* alternative replacement options ie bridge
Sensibility test
* pulp response
radiographic assessment prior to dx
2 angles (30 degrees mesial or distal beam shift)
or CBCT
Parallax – find out if resorption buccal, lingual or external/internal
* If resorption moves – external
* If fixate/centre in tooth – internal
Single biggest thing to aid dx – internal balloons out from internal aspect of canal
* Parallel lines of RCS lost (tramlines) = INTERNAL
* External = superimposition of resorption – can still see tramlines of pulp, internal aspect of RCS intact
clinical findings for internal inflammatory resorption
Coronal integrity
* can be unrestored
Periodontal pocketing
* nil unless lesion has perforated root surface
Colour
* normal
Sinus
* nil unless periradicular disease
Swelling
* nil
Apical tenderness
* nil
Tenderness to precision
* nil
Mobility
* normal
Sensitivity
* positive response
Incidental finding
V little signs and symptoms
Positive response usually
what to do when get internal resorption but also peri-apical radiolucency
when gets big and get PA radiolucency – whole RCS necrotic
* pathological process (giant cells nibbling at tooth) – need vital blood supply for this to occur
Coronal aspect necrotic - contributed to internal resorption starting
* lesion includes inflammatory and vascular tissue - if perforated will communicate with PDL
* vitality in apical part of RCS – lesion will continue to progress until apical pulp goes completely necrotic
once get PA – whole system non vital
* resorption stopped – less complications; not as urgent for tx
tx for inflammatory internal resorption
orthograde endodontics only
possible haemorrhage
* Necrotic pulp – black
* Vital pulp – pink
active irrigation
* need to access resorption defect to kill cells to stop process
* CaOh can be useful if not happy with disinfection process then obturate – can use active irrigation
intervisit medicament
thermal obturation
internal replacment resorption
clinical findings
radiographic findings
- Coronal integrity can be unrestored
- Periodontal pocketing nil
- Colour nil
- Sinus nil
- Swelling nil
- Apical tenderness nil
- Tenderness to precision nil
- Mobility normal
- Sensitivity positive positive
Radiographically
- Pulp is big - Pulp chamber has radiopactities – pulp is replaced by mineralised (not bone, dentine, cementum is a mix)
- RCS slightly expanded
tx for internal replacment resorption
Hard to tx – chisel, high chance # file,
Accept monitor and plan for definitive when become symptomatic
Risks of RCT outweigh benefits of RCT
rare
external root resorption common finding
pt present with mobile tooth
external surface resorption
clinical findings
radiographic findings
- Coronal integrity can be unrestored
- Periodontal pocketing nil
- Colour nil
- Sinus nil
- Swelling nil
- Apical tenderness nil
- Tenderness to precision nil
- Mobility inc physiological mobility
- Sensitivity positive positive
**PDL intact, no PA radiolucency **– no need for endo (used to preserve pulp, tx periradicular disease)
key feature of external surface resorption
PDL intact, no PA radiolucency
no need for endo
common aetiology for external surface resorption
Ortho
90% of teeth have some form ESR
* 2-5% severe ESR
* 15% moderate
Usually the teeth for anchorage are worst affected
what has happened here
Trabecular pattern in area of resorption – healed, but still external surface resorption
Can be caused by
* Ectopic teeth – pressure from erupting tooth
* Pathological lesions - ameloblastomas
* idiopathic
tx for external surface resorption
The PULP is HEALTHY - Endodontic treatment will NOT have any effect REMOVE the SOURCE to stop the resportion …..splint if mobile
Plan for failure of the teeth involved – monitor
external inflammatory resorption
clinical findings
radiographic findings
Coronal integrity usually restored
Periodontal pocketing nil
Colour nil
Sinus possibly
Swelling possibly
Apical tenderness possibly
Tenderness to precision possibly
Mobility maybe increased depending on extent
Sensitivity negative as the pulp is necrotic
Necrotic pulp so INFLAMMATION going on around it
Persistent periapical radiolucency - apex nibbled away by chronic inflammation
common presenting factors for external inflammatory resorption
restoration encroaching on pulp PA and resorption mesial root, trauma
PA radiolucency, apex nibbled away, incisor has bad endo inflammation grown to overlap canine
* need to remove inflammation source to solve (endo canine wont solve alone)
aetiology of external inflammatory resorption
The pulp is necrotic - bacterial or dental trauma in origin
The periapical inflammatory lesion precipitates the resorption process
In actual fact the majority (81%) of teeth with periapical lesions will have microscope areas of root resorption
* Only 7% of these are detectable radiographically
manegemnt of external inflammatory resorption
REMOVE the CAUSE of the INFLAMMATION - Usually orthograde ENDODONTIC (re)TREATMENT possibly surgical endodontics or extraction
is there still have apical control – constriction
* may need to manufacture (peri radicular)
external replacment resorption
clinicaly findings
Coronal integrity can be unrestored but infraoccluded
Periodontal pocketing nil possible erythematous
Colour nil
Sinus nil
Swelling nil
Apical tenderness nil
Tenderness to precision nil but high pitched notes
**Mobility no physiological mobility **
Sensitivity positive
Hear difference in TTP
**Pt still growing will get infraocclusion **
external replacement resorption
radiographic findings
Radiographically
* Root is disappearing and getting filled in with bone
* Loss of PDL
* Trabecular pattern bone infil with root disappearing
aetiology of external replacment resorption
Trauma – significant injuries to periodontium – avulsion or intrusion or lateral luxation
Bone (osteolcasts) is then in contact with external root dentine to begin resorption
tx for external replacment resorption
if pt still growing
DECORONATION If infraocclusion is more than 1mm in a growing patient
Remove crown to alveolar level and allow root to resorb
* This preserves bone volume
* Adjacent teeth and periodontium develop normally – prevent soft tissue defect
* Tooth replacement with denture or RBB
if delayed decoronation - hard and soft tissue defects (asymmetry, tip)
tx for external replacment resorption in non growing pt
Endodontic intervention will NOT STOP the resorption
Because of infraocclusion can add composite incisally
* If need endo - Fill with CaOH and place in – will resorb with tooth and not get stick in bone like GP
external cervical resorption
clinical findings
Coronal integrity can be unrestored
Periodontal pocketing yes if extensive and profuse BOP
Colour pink spot
Sinus nil
Swelling nil
Apical tenderness nil
Tenderness to precision nil
Mobility normal or nil
Sensitivity positive
Classic findings – subgingival cavity hard to probe, pink spot on crown, positive sensibility – but large clinical variety
Last pic also replacement as infraocclusion
4 classical signs of external cervical resorption
profuse BOP
subgingival cavity hard to probe,
pink spot on crown,
positive sensibility
external cervical resorption
radiographic findings
Apple cores out from CEJ
* Can still see tramlines of RCS – external
* Beam shift – resorption detection moved, opposite direction – labial external defect
LARGE incidence, LARGE variety
CBCT good for pulp proximity
classification of external cervical resorption
Defined by 3 criteria’s
Apico-coronal direction
1. crestal
2. coronal 1/3
3. middle 1/3
4. apical 1/3
Circumferential
1/4
1/2
3/4
More than 3/4
Last one is encroaching/communicate with pulp??
aetiology of external cervical resorption
LARGE incidence, LARGE variety
- Orthodontics
- Trauma - avulsion and luxation +historical non vital whitening when heat was applied
- Wind instruments
- Viral infection
- Systemic disturbance - thyroid
important cellular level consideration for external cervical resorption
Irregular front of resorption – imp for chemical and physical disinfection
* Predentine layer in tact – protecting the pulp itself, resorption around it
tx options for external cervical resorption
**Monitor – resorption will likely continue **
Internal repair and orthograde endo
Proximal cannot access – need internal repair - Tx like perforation repair with elective endo tx
* Microbursh NaOCl – bleeder, stranfs of resorption, cause coagulation necrosis? Need to get rid of them prior to restore to prevent resorption continue (Cannot just lift out and ping out and place restoration)
* Flowable composite on perforation
* Glass ionomer for cervical regions – not in occlusal loading place so strength ok, wet
Extraction and prosthetic replacement Or decoronate
Think about where it is and how to access – don’t want to destroy midline papilla by raising flap – decoronate instead
considerations for external cervical resorption
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- extent of lesion - is it restorable, is it accessible
- proximity of pulp and crestal bone
- debridement chemically and physically
- how good is moisture control for restoration
considerations for internal inflammatory resorption
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- extent of lesion - is it restorable, is it perforated
- has the pulp become completely necrotic
- challneges - haemostasis, disinfection, obturation
- adjuntive irrigation with active irrigation
- intervisit medicament - nsCaOH paste
- warm vertical caompaction or use MTA if perforated
